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Enteral nutrition
Lecture 12
21
Pharmacology
Professional
11/01/2012

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Term
What is enteral nutrition?
Definition
Delivery of nutrients via mouth or feeding tube into the GI tract.
**Macro nutrients - protein, fats, carbs
**Micro nutrients - vitamins and minerals
Term
When is enteral feeding considered?
Definition
- Inable to ingest food normally - dysphagia (stroke, cancer, acalasia), comatose, or ventilation
- Inadequate nutrition due to a disease state
- Inadequate oral intake after 5-7 days
**Hypermetabolic states such as burns may require enteral feeding.
Term
What is the advantage of enteral nutrition?
Definition
If the gut is used, it does not atrophy. Atrophy leads to bacterial translocation.
Reduced infection compared to parenteral.
Term
Why is protein essential in EN?
Definition
Although it is the 3rd line for energy, some amino acids are ESSENTIAL.
Albumin maintains fluid balance.
Term
What macronutrient is the 1st line for energy in EN?
Definition
Carbs! Specifically glucose
Term
What fats are used for EN?
Definition
Omega-3 (linoleic) and omega-6 (alpha linolenic acid) b/c these are not produced by the body
Combo of middle and long chain TGs
Term
What different enteric feeding formulas are available?
Definition
- Standard polymeric - for general patient population
- High protein - wounds and burns
- High calorie - fluid restriction
- Elemental - intolerance to standard formula
- Peptide base - intolerance to standard formula
- Renal - renal failure
- Hepatic - hepatic failure
- Respiratory - ARDS and ALI
- DM - hyperglycemia
- Immune-modulating - trauma or stress
Term
Why is ensure not preferred for EN?
Definition
It is sweetened for oral use, thus it is hypertonic
Term
What routes are available for short term EN?
Definition
First line: Orogastric or nasogastric
Not preferred: nasoduodenal or nasojejunal
**Small bore more prone to occlusion
Term
What routes are available for long term EN?
Definition
- Percutaneous endoscopic gastronomy - large bore
- Percutaneous endoscopic jejunostomy
- Percutaneous gastrojejunostomy
Term
When is small bowel access appropriate for EN?
Definition
- Gastric obstruction
- Gastroparesis
- Pancreatitis
- Fistulas
- Aspiration
Term
What is the difference between open and closed systems for EN?
Definition
- Open system - transfer to a refillable bag. Risks contamination
- Closed system - ready to hang
**Use sterile liquid formulations whenever possible. Use sterile water for hydration
Term
When should and enteral tube be flushed?
Definition
With 30 mL every 4 hours, or before and after feeding or medication administration
Term
How is a protein goal determined?
Definition
Goal will be Protein g/kg --> dependent upon weight and status
Volume: Protein/55.5 * 1000 mL = volume in 24 hours
**Volume/24 = rate per hour.
Term
How is free water volume determined?
Definition
TF rate * 24 = total TF volume
Total volume * % free water of formula = free water
**Water for hydration --> Total calories of formula - free water. May divide by shifts.
Term
What are barriers to enteral nutrition delivery?
Definition
- Tests, surgery, procedures
- Hypotension
- Access
- Hypocaloric orders (watch propofol)
- GI intolerance
- Drug-nutrient interactions.
Term
What are signs of enteral feeding intolerance?
Definition
Electrolyte abnormalities
GI intolerance - N/V
High lactic acid
Abdomninal distention
Metabolic acidosis
GRV > 250
Constipation or aspiration
Term
What drugs can be used to treat GI dysmotility?
Definition
- Metoclopramide/Reglan - DA2 antagonist
- Erythromycin - has motilin activity.
- Opioid antagonists - naloxone and methylnaltrexone
Term
How is constipation treated with enteral feeding?
Definition
Fluids
Prune juice
Fiber
Correct K/Mg levels
Laxatives: Docusate for maintenence, use in combo w/ bisacodyl or sennosides. Mineral oil last line.
Term
How is diarrhea treated in enteral feeding?
Definition
- Loperamide
- Lomotil
- Tincture of opium
Term
When should enteral feedings be started in the critically ill?
Definition
within 24-48 hours, withhold until hemodynamically stable
**Watch for signs of bowel ischemia, especially in patients on fiber formulas
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